Affix

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Photograph
duly attested

APPLICATION FORM

M PHIL. IN CLINICAL PSYCHOLOGY

UNIVERSITY OF CALCUTTA
UNIVERSITY COLLEGE OF SCIENCE, TECHNOLOGY AND AGRICULTURE
To
The Secretary
Faculty Councils for P.G. Studies in Sc., Tech.& Engg and Ag. & Vet. Sc.
Calcutta University
92, A.P.C. Road, Kolkata 700 009
Name of the Applicant (in block letters): __________________________________________________
M.A. / M.Sc. with Subject: ______________________________________
College and University: _______________________________________________________________
Year of entry in MA/ M.Sc.: __________________________ Year of passing: ______________
Applied for admission in
Course: ______________________________
Subject: ______________________________
Whether admitted earlier in this course, give details: ____________________________
Date of birth: ________________ Whether employed: _____________________________
Category:
GEN
SC
ST
PH
Statement of marks in MA/M.Sc. examination:
Examination

Semester
/ Part

SGPA

CGPA

Total marks
obtained

Total marks of
exam

Class/Div.,

%
of marks

I
II
III
IV
V
VI
VII
VIII
Statement of marks in the following Examinations:
Examination

Board/
University

Year of
passing

Total marks
obtained

Full marks
of exam.

Grade/
GP

Madhyamik or equiv.
(10)
HS or equivalent
(10+2)
B.Sc.(Hons.)
(10+2+3)
Other Qualifications

Details of the Bank Draft (submitted along with this application form):
(DD in favour of M. Phil in Clinical Psychology, C. U., payable at Kolkata)

Class
/Div.

%
of marks

UNIVERSITY COLLEGE OF SCIENCE, TECHNOLOGY AND AGRICULTURE

1.
2.
3.

4.

5.
6.
8.
9.
10.
11.
12.
13.
14.

Name of the applicant (in block letters)

Calcutta University Registration No. (for C.U. Students)..
Present address (if any)
..
.
Telephone No.Mobile..Email :..
Permanent address . ..
.

Telephone No.
Nationality . Domicile state
Male / Female . 7. Married / Unmarried.
Fathers Name ... Occupation .. Monthly Income .
Mothers Name .. Occupation .. Monthly Income ..
Husbands /Wifes name Occupation .. Monthly Income
Guardians name, relationship and occupation .
Income of the family per month
Are you enjoying any scholarship or stipend (if yes, state the name of the sponsor) :
Details of employment (if employed)

DECLARATION / UNDERTAKING
I do here by declare / undertake that the statements made above by me are true. If any error/misinformation is detected after
my provisional admission, my admission shall be treated as cancelled. I have not taken admission nor shall I take admission
to any other course during my studies in this University without intimation. If I get admission I will be a full time student of
this University. I am aware that, as per RCI guidelines for M.Phil in Clinical Psychology (2009) minimum attendance of 80%
(in the academic year) shall be necessary for taking the respective examination (Part I or Part II).
Endorsed
____________________________________
Signature of father/mother/husband/guardian

Date .

___________________________________
Signature of the applicant

Date .

N. B.
1.
2.
3.
4.

Application must be accompanied self-attested copies of all relevant Mark Sheets and Certificates as applicable
For Sponsored candidates Employer Certificate must be attached to the application form
All documents and photo submitted must be signed by the candidate himself/herself.
Incomplete Forms are liable to be rejected.